Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Gwen - Neurology > Stroke and TIA - Acute investigation and Management > Flashcards

Stroke and TIA - Acute investigation and Management Flashcards

1
Q

Investigations of stroke

A

Blood tests

  • Us and Es

Risk factors for atheroma

  • BP
  • Blood tests
    • Glucose
    • Cholesterol
    • Thyroid function (AF risk)
    • LFT (alcohol consumption)

Sources Embolism

  • Heart
    • ECG
    • Echo (cardiac thrombus, valvular disease)
    • Blood cultures
    • 24hr tape
  • Neck and intracranial vessels
    • Carotid doppler
    • Angiogram/MRI

Causes of tendancy to thrombosis

  • Blood tests
    • FBC
    • Thrombophillia screen (protein C+S, lupus anticoag)
    • Sickle cell screen

Causes of inflammatory vascular disease

  • Blood tests
    • ESR
    • Syphillis serology
    • Temporal art biopsy

Bold = all stroke patients

Imaging

  • CT to differentiate between infarct and haemorrhage
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Difference beetween infarct and haemorrhage on CT?

A

Dark = infarction

White = haemorrhage

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Key questions to ask yourself when assessing a stroke

A

1. Is it a stroke

2. What kind of stroke

CT/MRI
History and exam

3. Why did the stroke occur

Ix used depends on the clinical picture

Eg:
Possible cardiac source? Full cardiac work up
Small stroke anterior circulation? Carotid doppler
Haemorrhagic? Clotting profile, cerebral angiography (AV malformations)

4. Worsening factors

Systemic metabolic disturbances
Esp hypoxia and hyperglycaemia will affect function of ischaemic brain and worsen stroke

Appropriate fluid balance/monitor Us and Es

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

If someone presented with clinical features suggestive of a stroke, what would you do?

A
  • ABCDE
  • History - Exact onset, changes/progression, Risk factors
  • Examination - full neuro exam, systemic and risk fcator exam
  • CT - within 1 hour presentation
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

When would you treat hypertension in someone presenting with a stroke?

A
  • Hypertensive emergency (encephalopathy/aortic dissection)
  • If thrombolysis is being considered
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

How long after presentation with symptos of a stroke should someone get a CT head?

A

Within 1 hour

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

When is CT/MRI within the first hour of presentation with stroke sypmtoms essential?

A
  • If thrombolysis considered
  • High risk of haemorrhage
  • Unusual presentation - fluctuating consciousness
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What is the most sensitive imaging modality for detecting acute infarction?

A

Diffusion-weighted MRI

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What happens at a cellular level when cerebral infarction occurs?

A

Hypoxic damage:

  • Na+/K+ pump Fails -> Na+ accumulates in the cell -> osmotic shift into cell -> cellular swelling
    • Cells in the immediate area around the infarct die very quickly, as they swell and burst. Cells in ā€œpenumbraā€ are relatively less oematous, and can be ā€œsavedā€
  • Excitotoxicity - Damage as a result of prolonged depolarisation of cells in affected area
    • Results in failure of AMPA and NMDA receptors - allows excessive calcium into the cell. This causes release of free radicals, production of cytokines, and direct apoptotic effects in the penumbra
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What specific things might you look for on examination in someone presenting with features of a stroke?

A
  • Thorough, full neruo exam - clinical diagnosis and lesion localisation
  • Pulse (AF)
  • Heart sounds (valve disorders)
  • Carotid Bruit
  • Signs of PVD
  • Bruising/Bleeding
  • Xanthalasma/Xanthoma/Corneal arcus
  • Tar Staining
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

When would you consider thromblysis in someone presented with a stroke?

A

Once haemorrhage has been excluded as cause, and within 4.5 hour window of onset (benefits outweigh risks within this window)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Within what time frame are the best results achieved using thrombolysis?

A

Within 90 minutes of onset

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What thrombolytic agent is most commonly used in stroke management?

A

Alteplase

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are contraindications to thrombolysis in a stroke?

A

Look them up - Impossible to remember all of them!!! - think of categories of contraindications

  • Stroke related
  • Neurological
  • Bleeding tendency
  • Trauma
  • Medical problems
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are stroke related contraindications to thrombolysis

A
  • Rapidy improving symptoms
  • Ischaemia of >1/3 MCA territory
  • Symptoms suggestive of SAH
  • Seizure at start of stroke
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are neurological contraindications to thrombolysis?

A

History of intracrnal bleed, aneurysm or neoplasma

Spinal or cranial surgery/injury

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What bleeding tendency risk factors are contraindicaitons to thrombolysis?

A
  • Significant bleeding disorder
  • Therapeutic anticoagulation - LMWH, DOACs, Warfarin
  • Iron deficiency anaemia
  • Thrombocytopenia
  • Advanced liver disease
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What are trauma related contraindications to thrombolysis in stroke?

A
  • Significant head injury <3 months
  • Major surgery/delivery/external heart massage <2 weeks
  • Puncture of non-compressible blood vessel <2 weeks
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What medical problems are contraindications for thrombolysis in stroke?

A
  • SBP > 180/DBP >110
  • Active internal bleeding
  • Aortic aneurysm
  • Bacterial endocarditis/pericarditis
  • Acute pancreatitis
  • Haemorrhagic retinopathy
  • Oesophageal varices
  • Ulceratie GI disease <3 months
  • GI/GU haemorrhage < 3 weeks
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

If thrombolysis was contraindicated, what treatment would you start someone on for acute treatment of a stroke?

A

Aspirin PO/PR OD for 2 weeks

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Why does diffusion weighted MRI detect early abnormalities seen in infarction better than normal MRI or CT?

A

This type of MRI exploits the fact that damaged cells fill with water ā€“ and thus contain more water than normal cells in the early stages of damage.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What intial investigations would you consider doing in someone presenting with a stroke?

A
  • CT/MRI - within 1 hour
  • MRI angiography
  • ECG
  • CXR
  • Bloods - ESR, FBC, clotting screen, glucose, Lipids/cholesterol
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Why might you do an ESR on someone presenting with features of a stroke?

A

If with headache and tender scalp - Giant cell arteritis

24
Q

Why might you do FBC or clotting in someone presenting with a stroke?

A

Look for evidence of clotting/bleeding disorders - thrombocytopenia, polycythaemia

25
Q

What would you want to prioritise in your ABCDE assessment in someone presenting with a stroke?

A
  • Maintain airway
  • Prevent hypoxia
  • Hydrate
  • Treat fever / source of fever ā€“ this can help to limit the extent of damage
  • Treat hypo / hyperglycaemia
26
Q

What dose of aspirin would you give someone if thrombolysis was contraindicated?

A

300 mg

27
Q

How long would you put someone on aspirin treatment for following a stroke?

A

2 weeks

28
Q

Primary management of ischemic stroke?

A

Thombolysis within 4 hours - alteplase, consider contraindications.

Aspirin (300mg) daily - given as soon as possible after onset of stroke symptoms once brain imaging has excluded haemorrhage

Hypertension managment - only lowered in acute stage where there are liekly to be complications (hyptensive encephalopathy, HF or aortic dissection)

29
Q

Secondary stroke management of ischaemic stroke

A
  1. Anti-hypertensives (ACEI)
  2. Antiplatelets (Aspirin + Dipyridamole or Clopidogrel)
  3. Statins
  4. Warfarin for AF
30
Q

What medication would you start someone on following 2 weeks of aspirin treatment?

A
  • Clopidogrel long term - monotherapy
  • Consider Warfarin if AF the cause
  • Statin - 48 hours after stroke
31
Q

What dose of clopidogrel would you give someone as long-term prophylaxis?

A

75 mg OD

32
Q

What could you give someone if they did not tolerate clopidogrel for post-stroke prophylaxis?

A

Slow-release dipyridamole

33
Q

What is the definition of a transient ischaemic attack?

A

A brief episode of neurological dysfunction due to temporary focal cerebral or retinal ischaemia without infarction, e.g. a weak limb, aphasia or loss of vision, usually lasting seconds or minutes with complete recovery. TIAs may herald a stroke. The arbitrary time of <24 hours is no longer used.

34
Q

If someone presented with a TIA with amaurosis fugax, where might the occlusion be taking place?

A

Retinal artery occlusion

35
Q

What are causes of TIA?

A
  • Atherothromboembolism
  • Cardioembolism - Mural thrombus, AF, Valve disease
  • Hyperviscosity - polycythaemia, sickle-cell, myeloma
  • Vasculitis - cranial arteritis, SLE, PAN
36
Q

What are features of an anterior circulation TIA?

A

Carotid system

  • Amaurosis fugax
  • Aphasia
  • Hemiparesis
  • Hemisensory loss
  • Hemianopic visual loss
37
Q

What are features of a posterior circulation TIA?

A
  • Diplopia, vertigo, vomiting
  • Choking and dysarthria
  • Ataxia
  • Hemisensory loss
  • Hemianopic visual loss
  • Bilateral visual loss
  • Tetraparesis
  • Loss of consciousness (rare)
  • Transient global amnesia (possibly)
38
Q

If, on examination of someone presenting with signs of a TIA, you found there to be central retinal artery occlusion, where might this suggest there is stenosis in the carotid system?

A

Internal carotid artery stenosis

39
Q

What differentials would you want to consider in someone presenting with features of a TIA?

A
  • Hypoglycaemia
  • Migraine aura
  • Focal epilepsy
  • Hyperventilation
  • REtinal bleeds
  • Malignant hypertension
  • MS
  • Intracrnaial tumours
  • Peripheral neuropathy
  • Phaeochromocytoma
  • Somatization
40
Q

What investigations would you consider doing in someone with a suspected TIA?

A
  • Bloods - FBC, U+Eā€™s, Glucose, Lipids
  • CXR
  • ECG
  • Carotid doppler +/- angio
  • CT/Diffusion weight MRI
  • ECHO
41
Q

How would you manage someone with a TIA?

A
  • Control risk factors - BP, DM, Hyperlipidaemia, Smoking
  • Antiplatelet therapy - Aspirin (300mg) for 2 weeks, then clopidogrel (75mg) long-term
  • Consider anticoagulation - AF
  • Consider carotid endartectomy - within 2 weeks of presentation if >70% stenosis and no contrindiations
42
Q

How long after a TIA are individuals not allowed to drive?

A

1 month - Need to inform DVLA if stll symptomatic after 4 weeks or HGV driver

43
Q

What scoring system could you use to stratify those who have had a TIA who might be at higher risk of stroke in the future?

A

ABCD2 score - score >/=4 indicates high risk of early stroke - assess by specialist in 24 hours

44
Q

Contraindications to thrombolysis

A

AGAINST
Aortic dissection
GI Bleeding - internal bleeding
Allergic reaction previously
Iatrogenic - recent surgery
Neurological - cerebral enoplasm, recent haemorrhage stroke (on CT), low GCS
Severe hypertension (>180/90mmHg)
Trauma - including CRP

So - NO MOTOR DEFICIT, SYMPTOM ONSET >3HOURS< IMPARIED CONSCIOUSNESS, COAGULOPATHY (INR>1.8)

45
Q

How does alteplase work

A

Converts plasminogen to plasmin which degrades fibrin to FDP

Ie decreaese platelet aggregation

46
Q

Potential surgical management of stroke

A

Carotid endarterectomy - for those with >70% stenosis (surgical excision of atheromatous segments)

Large intracranial haematoma (surgical excision)

Large cerebellar stroke (brain stem compression)

47
Q

Secondary stroke managmenet:

ASPIRIN: SE, Cautions, Contraindications

CLOPIDOGREL: When, SE

A

Aspirin:

  • 300mg 2 weeks
  • NSAIDs can antagonise effects so withhold during 2 weeks of aspiring use
  • Inhibits thromboxane 2
  • SE: GI irritation/bleed
  • Cautions - asthma, uncontrolled hypertension, previous peptic ulcer
  • Contraindications - Known allergies, GI ulcers, pregnant

Clopidogrel

  • 2 weeks postischaemic (after aspirin) or post TIA
  • SE: Dyspepsia, abdo pain
  • PPIs could reduce efficacy
48
Q

Secondary stroke management:

STATINS

SE, Monitoring, Interactions, whats first line

A

SE: Myopathy, GI effect, altered LFTs

Monitoring: LFTs measured prior to therapy after 12 weeks and then annually, non fasting total cholesterol, TFTs, HbA1C

Interactions: Antiarrhythmitics, antibiotics (macrolides) - stop statin for period for period of antibiotic use, anticoagulants, graperuit juice

First line: Atorvostatin 80mg

49
Q

Secondary stroke management:

Antihypertensives

Common used?
SE

Monitoring

A

Perindopril and indapamide

SE: Dry cough, dizziness/first dose hyptension, AKI, angioedma, hyperkalaemia

Monitoring: Us and Es (renal function, potassium)

50
Q

Secondary strok managmenet:
Anticoagulants
When used?
When witheld?

A

When used - ischaemic patients with AF

Aspirin 3 days then start anticoagulant

Eg Endoxaban

51
Q

What medication would you expect someone to be on day 2 post stroke?

A

Aspirin

Artorvostatin

52
Q

What medication would you expect someone to be on 16 days post stroke?

A

Clopidogrel

Atorvostatin

Perindopril

Indapamide

Endoxaban in patinets with AF

53
Q

Carotid symptoms TIA

A

(POSTERIOR)

Amarosis fugax

Aphasia

Hemiparesis

Hemisensory loss

Hemianopia visual loss

54
Q

Vertebro-basillar teritory symptoms

A

(ANTERIOR)
Diplopia

Vertigo

Vomiting

Dysarthria

Choking

Ataxia

Hemisensory loss

Visual loss

Paresis

55
Q

Signs of TIA

A

Carotid bruit

Hypertension

AF

Heart murmur from vascular disease

Fundoscopy during TIA - retinal artery emboli

56
Q

DDx TIA

A

Migraine

Partial seizure

Transient global amnesia

Intracranial lesions

Metabolic hypoglycaemia

Peripheral nerve lesions - in intermittent sensory loss

57
Q

Management of TIA

A

Aspirin 300mg + Dipyridamole (Clopidogrel if intolerant) - aspirin given 2 weeks after for life post TIA

Warfarin (AF)

Carotid endartectomy

Secondary prevention - control of risk factors

Gwen - Neurology (38 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions